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Home , Distal radius fracture, Open fracture

Distal Fractures: Treatment Options Melvin P. Rosenwasser, MD Robert E. Carroll Professor of Surgery Chief, Orthopaedic Hand, Trauma Services Director, Trauma Training Center Columbia-Presbyterian Medical Center

Introduction ● Goal: recovery of normal function: restore natural bow of the radius to maintain motion and grip strength normalization of length axial alignment rotational alignment ● Evaluation Neuro-vascular exam of the can occur secondary to injury Tense swelling, pain with passive motion, Forearm fasciotomy ● Radiographs AP, lateral, oblique [also include , elbow, with special attention to DRUJ. ● Etiology High energy trauma: MVA, fall from height, GSW

Anatomy ● Articulation of the distal radius with the scaphoid and lunate of the carpus The distal radioulnar joint (DRUJ) Articulation of distal with the triangular fibrocartilage complex (TFC) The TFC articulates with both the lunate and the triquetrum of the carpus. The scaphoid and lunate fossa are two concave articular surfaces separated by a dorso- volar ridge. A third concave articulation, the sigmoid notch, exists for the head of the ulna. The contact area with the TFC varies with changing degrees of rotation of the wrist. The amount of force transmitted between the TFC and the radius therefore varies with changing degrees of pronation and supination. In supination, the ulnar head displaces volarly in the sigmoid notch, while in pronation it rotates dorsally. ● Normal : Distal Radius Radial inclination angle: 23 degrees (AP x-ray) Volar tilt (palmar inclination angle): 10 degrees (Lateral x-ray) Ulnar variance (radial length): mean -0.9 mm (AP x-ray)

Classification ● AO/ASIF classification of diaphyseal forearm fracture patterns Ratio of open fractures to closed is higher for forearm than other bones except Increased incidence of nerve laceration Debridement, irrigation, rigid fixation ORIF within 24 hours: , intramedullary nailing, or plating antibiotics Prevention of infection is necessary to avoid malunion, , loss of function and Comminuted fracture Standard plating Lag-screw fixation of the pieces Defect can be grafted ● Frykman Classification System 8 categories Considers ulnar styloid Does not consider direction or amount of displacement of fracture fragments AO Classification System 27 total fracture patterns Highly detailed but unwieldy for easy use and memorization ● Melone Classification System Applicable only to intra-articular fractures Helpful in understanding the ‘die-punch’ lesion ● The Problem with Classification Systems Andersen DJ, Blair WF, Steyers CM Jr, Adams BD, el-Khouri GY, Brandser EA. Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J Hand Surg 1996;21A(4):574-82. Analyzed inter/intra observer agreement for Frykman, AO, Melone, and Mayo systems None of the systems showed substantial interobserver agreement

Instability ● Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20(4):208-10. ● La Fontaine (1989) criteria: Dorsal tilt >20 degrees Dorsal comminution Intra-articular fracture Associated ulnar fracture Age over 60 years ● 3 or more tended to collapse

Treatment Options

● Tools to work with in achieving best reduction Plaster Pins External fixation Plates Screws Bone graft or filler

Criteria for Acceptable Reduction ● Change in volar (palmar) tilt < 10° (ie, neutral or 20 palmar slope) ● Radial shortening < 2 mm ● Change in radial angle < 5° ● When intra-articular fracture is present: Articular step-off < 1-2 mm

Rationale for the Guidelines ● Intra-articular step-off Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68A(5):647-59. 2 mm step-off on AP x-ray greatly increased the risk of symptomatic at 7 year follow-up Dorsal tilt and radial length not much affect on outcome

Intra-Articular Incongruency ● Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19A(2):325-40. 3 year follow-up of 52 fx’s Single most important factor that correlated with outcome was intra-articular gap between fragments Residual loss of volar or radial tilt did not correlate with outcome ● Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and . J Bone Joint Surg 1997;79A(9):1290-302. 7 year follow-up of 26 fx’s All treated with surgery Residual articular displacement (CT scan and x-ray) correlated with radiographic changes but not with functional outcome

What is Important? ● Does the fracture extend to the opposite cortex of the radius?

i.e., volar cortex for Colles ● Percutaneous fixation alone Extra-articular fracture Younger patient (good bone stock) Good soft tissue envelope Need adjunctive cast/brace ● ‘Kapandji’ Intrafocal Pinning A technique of K-pinning using the pin itself to buttress the fracture site; usually requires ex-fix or cast ● Pin Placement Pins are placed avoiding any contact with flexor tendons

Contraindications ● Significant intra-articular displacement ● Volar cortical comminution ● Inability to obtain an anatomic reduction

Clinical Results ● Greatting MD, Bishop AT. Intrafocal (Kapandji) pinning of unstable fractures of the distal radius. Orthop Clin of North America 1993;24(2):301-7. 23 patients, 24 unstable fx of distal radius 2 to 3 0.062 K-wires maintained for 4 weeks 6 weeks Short Cast Results: Patients < 65 years of age 79% good or excellent radiologic results Patients > 65 years of age 60% good or excellent radiologic results UNION IN ALL PATIENTS ● Trumble TE, Wagner W, Hanel DP, Vedder NB, Gilbert M. Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg 1998;23A(3):381-94. Trumble TE, et.al. J Hand Surg 1998;23A(3):381-94 73 patients Kapandji pinning with or without ex fix All had dorsally displaced extra-articular fx Results: Older patients Range of motion, grip strength & pain relief significantly better w/ ex fix Younger patients w/ comminution of only 1 surface Good results w/ Kapandji pinning alone w/ comminution of > 2 sides

Better results w/ ex fix ● Stoffelen DV, Broos PL. Closed reduction versus Kapandji-pinning for extra-articular distal radial fractures. J Hand Surg 1999;24B(1):89-91. 98 patients with extra-articular distal radius fractures Prospective randomized trial Results Closed Reduction and Plaster Cast Group 74% good, excellent Cooney score Kapandji-Pinning Group 75% good, excellent Cooney score

Volar Plating with Extra-articular plates 1. Approach Make longitudinal incision slightly radial to the flexor carpi radialis tendon (FCR). Dissect between FCR and radial artery. 2.

External Fixation ● ‘Ligamentotaxis’ pulls on the fracture fragments to reduce and prevent collapse ● Cannot restore normal volar tilt by pulling straight distally alone, a palmar vector is required ● External Fixation Advantages Easy to apply Access to wound/pins ‘Neutralizes’ fracture site Frees up the elbow Light ● External Fixation Disadvantages Does not necessarily reduce the fracture alone Possible pin-tract infection ? more stiffness with excessive distraction

Non-Joint Spanning Ex-Fix: What’s New? ● Indications Unstable extra- or intra-articular distal radius fractures (DRF) Failed closed reduction Distal fragment size ≥ 6mm McQueen recommends ≥ 10mm Young patient Good bone stock ● Treatment Options Closed reduction - cast Percutaneous pinning - cast

Pinning - ExFix ORIF Dynamic ExFix Non-joint spanning ExFix ● Patient’s Trauma 30 year old male sustained right while snowboarding Injury occurred 10 days prior to operation X-ray reveals a minimally displaced right distal radius fracture with a noticeably depressed lunate fossa as well as loss of volar tilt.

Benefits (Non-joint spanning ExFix) ● Rigid anatomic fixation ● Early motion ● Normal carpal load transfer / mobility ● Avoids late stiffness (no ligamentotaxis)

Technical Considerations ● What I use ● Standard proximal pins placement ● Mini C-arm to place distal pins ● Transverse pin placement ● Pins as joy-sticks to control fragment ● Radio-ulnar & volar-dorsal translation ● Both pins dorsally ● Supplement with percutaneous K-wires ● No ligamentotaxis = less stiffness?

Postop Care ● ROM after resolution of postop pain ● Interval splinting for 2-4 weeks (prevent pin tract infection) Fischer T, Koch P, Saager C, Kohut GN. The radio-radial external fixator in the treatment of fractures of the distal radius. J Hand Surg 1999;24B(5):604-9.

Patient’s Trauma ● 46 year old male sustained injury from a fall while roller skating Sustained markedly displaced, comminuted and impacted fracture of the left distal radius metaphysis with intraarticular extension. Closed reduction failed to maintain alignment

There was a radial neurapraxia of his left thumb and marked instability with displacement of his distal radius.

Clinical Studies ● Melendez EM, Mehne DK, Posner MA. Treatment of unstable Colles’ fractures with a new radius mini-fixator. J Hand Surg 1989;14A(5):807-11. 13 cases All extra-articular fractures All healed by 8.5 weeks Loss of radial length 0.5mm Loss of palmar tilt 2.2 degrees Loss of inclination 1.3 degrees ● Bishay M, Aguilera X, Grant J, Dunkerley DR. The results of external fixation of the radius in the treatment of comminuted intraarticular fractures of the distal end. J Hand Surg 1994;19B(3):378-83. 14 cases 79% excellent / 21% good results 12/14 anatomic X-Ray 2 patients with <2mm step-off ● McQueen MM. Redisplaced unstable fractures of the distal radius: a randomised, prospective study of bridging versus non-bridging external fixation. J Bone Joint Surg 1998;80B(4):665-9. Prospective randomized study, 60 cases Significant improvement: Radiographic measurements Functional outcome Results maintained at 1 year ● Krishnan J, Chipchase LS, Slavotinek J. Intraarticular fractures of the distal radius treated with metaphyseal external fixation. J Hand Surg 1998;23B(3):396-9. 22 cases (all intra-articular fractures) Functional ROM at 4 weeks post fixator removal ● McQueen MM, Simpson D, Court-Brown CM. Use of the Hoffman 2 compact external fixator in the treatment of redisplaced unstable distal radial fractures. J Orthop Trauma 1999;13(7):501-5. 20 cases Postop: Volar tilt 4 degrees Radial shortening 1mm Grip strength 74% contralateral limb ROM 80% 1 loss of fixation (dorsal angulation) ● Fischer T, Koch P, Saager C, Kohut GN. The radio-radial external fixator in the treatment of fractures of the distal radius. J Hand Surg 1999;24B(5):604-9.

17 cases 29 months follow-up findings (avg): Radial inclination 24 degrees Volar tilt 12 degrees Radial length 0mm

Complications ● Pin tract infections increased skin mobility volar interval splinting recommended Fischer JHS (B) 1999 ● Sensory nerve injury Nerve more vulnerable with distal radial pins Small skin incision recommended McQueen J Orthop Trauma (1999) ● Nonunion ● Malunion May be used after radial osteotomy for malunion Posner JHS (1989) ● Extensor rupture ● ● RSD

Conclusion Non-joint Spanning Ex Fix ● Unstable intra- and extra-articular fractures ● Distal fragment at least 6mm length ● Young patient or good bone stock ● Avoids ligamentotaxis ● Early motion ● Late results same or better

Full Open Reduction & Internal Fixation ● The primary indication is severe articular displacement, which if left untreated, may lead to radioulnar or radiocarpal arthritis.

Plates ● Volar buttress plating recommended for fractures that displace volarly Usually the distal screw holes are left open ● Dorsal Plating Recommended by some in lieu of ex-fix and K-pins

Requires extensive dissection Early motion usually not possible anyway Plates usually require removal

Specific Conditions and Treatment ● Barton’s Fracture Palmar Barton Ideally treated by a palmar buttress plate. Dorsal Barton (intra-articular Colles) Best treated by closed reduction and external fixation if adequate reduction can be maintained. Otherwise, open reduction and percutaneous pins, compressive screws, or a dorsal buttress plate can be used. Arthroscopic reduction of dorsal Barton’s fracture offers an alternative that limits exposure of the dorsal carpus and that may help maintain blood supply to the dorsal fracture components. Skill in arthroscopy is required for this procedure. ● Smith’s Fracture Open reduction and internal fixation (or external fixation) is the treatment of choice for palmar displaced fractures. External fixation for open Smith’s fractures is acceptable for wound considerations. It is rarely necessary to have distal screws in using the buttress plate for most Smith fractures, and there is risk of screws penetrating either the radiocarpal joint or extruding dorsally to affect the wrist and finger extensor tendons. A mini fragment plate is the exception to the general rule. ● Both-bone forearm fracture ORIF within 48 hours of injury Best achieved with 3.5mm compression plating, which is not removed after fracture healing. ● Galleazzi fracture. “fracture of necessity” Disruption of the DRUJ Occurs in 3-6% of forearm fractures Axial loading upon pronated forearm Key features are isolated distal radius fracture with: ulnar styloid fracture widened DRUJ on AP of wrist apex dorsal fracture and subluxation/dislocation of radius on ulna (lateral view) shortened distal radius >5mm relative to distal ulna

ORIF: radius is plated through an anterior approach. If the ulnar head is stable, the arm is held in supination for 4 weeks. If the head remains unstable, it is pinned to the radius for 4 weeks. If the RU is unreducible, the joint should be opened dorsally, inspected for interposed tendon or loose bodies and reduce.

Outcomes and Complications ● ORIF with 3.5mm dynamic compression plate achieves a union rate of 95-98% ● Schemitsch and Richards (1992) demonstrated 84% of patients managed with plating had an excellent, good or acceptable functional result 6 years post-op. Restoration of the normal radial bow was related to the functional outcome. A good functional result (more than 80% of normal rotation of the forearm) and recovery of grip strength were associated with restoration of the normal amount and location of the radial bow. ● Complications related to the severity and classification of the fracture. Chapman, et al (1989) demonstrated a rate of 13% for nerve injuries (9% radial, 2% median, 2% ulna) and 2% incidence of vascular injuries. Radioulnar synostosis has been reported in 2% of forearm fractures (Vince, 1987) Complication of a Galleazzi fracture: nerve injury to the dorsal sensory branch of the radial nerve

Operative vs. Nonoperative management in the elderly

Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010;92(9):1851-1857.

Case/control w/ 90 patients > 65 y/o, 82 treated operatively / 74 treated non operatively initially treated with closed reduction / splinting surgical management: volar locked plate or bridging external fixation nonsurgical management: treated until healing via cast immobilization 24 week f/u: surgical cohort showed better wrist extension 1 year f/u: no difference in wrist extension, but grip strength better for surgical management At all follow-ups: No difference is seen in DASH or pain scores No difference between groups with regard to complications

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